Documenting medical necessity for tummy tuck?

I have insurance coverage through Keystone HP East. Nine months ago I had WLS and I have lost 120 pounds. I have about 60 pounds to go before I reach my goal weight. I decided to be proactive about any potential tummy tuck surgery and find out now if Keystone covers the surgery and what criteria is required. The e-mail I got back from them stated that the tummy tuck would be required if it was medically necessary. So may questions are: has anyone had tummy tuck surgery covered by Keystone? And if so, what constitutes "medical necessity" for the surgery? Thanks for your help!

I don't have keystone and I have not had a tummy tuck.

What I can tell you is things I have read which help to necessitate medical necessity:

1)  Back/hip/knee/ankle joint problems/pain from extra weight pulling on the front of you (as documented by chiropractor, primary doctor, ect)

2)  Rashes (even if they are resolved temporarily by creams.  If they return, they count)  You need to have documented EACH time they occur.  So - even though you might be prescribed the same cream, go to the doctor EACH time you break out.  Have the doctor take pictures or take pictures yourself.

3)  Interference with personal hygeine - if the loose skin "hangs" over - covering your female parts - that can lead to vaginal/urinary tract infections.  Have this documented by your gyn.

This is what others have told me....I'm sure someone will have more answers for you.

Pam

things that make it medical necessity are things like serve itching skin, rashes, yeast infections, the skin pulling your joints and back out of place, also UTIs can be caused by to much skin down there... so there are some ideas... I know there are more but those are the ones I know about...

Betty,

I have KHPE, you can go to my profile and read the letter that I wrote and had my PCP sign.  I was approved within a month.  My cir****tances are a little different than most as I am still  about 100 lbs. from my goal, but my GBS wanted the surgery done.  Rashes, back aches, etc are considered medical necessity.  If you get rashes have your PCP start RX a cream for you and document each time you see him which will be every month.

Most important, when you submit the paperwork make sure that you have reconstuctive surgery listed and even put it on the envelope as an Attention.

Good luck.

I had my panni and hernia repaired in January.


Jeanne

can you please email me a copy of your letter     [email protected]

 

thanks you so much

Can you also email me the letter for panni.  My email is [email protected]. 

 

Thanks,

Deb

I get nasty rashes in the folds of skin.  I go to the doc every time I get one and have him document it.

Even when I treat them on my own with what he gave me I call and say that the rash is back so he can make a note on my chart.